의료수가 결정요인에 관한 연구

Abstract

Health Insurance benefits are the fees paid for medical services. When a medical provider provides medical services(medical procedure, medical device, pharmaceuticals) to consumers, the insurer(National Health Insurance Services, etc.) reimburse the incurred costs. Because the medical fee, which is the amount reimbursed in this process, is determined through government intervention, the government and medical providers have a conflict over the appropriateness of the medical fee level. At this time, the main content of the conflict is that the level of medical fees in Korea is set low compared to that of other countries. Therefore, with this conflict in the background, this study firstly checks whether there is a difference in Korea's medical fee(medical procedure, medical device, pharmaceuticals) level compared to other countries, and secondly, if there is a difference, consider what kind of combination of causal conditions(medical demands, resources, services, finance, publicity of health insurance system and regulatory strength) that determines the medical fees. The analysis was conducted on Japan, Taiwan, Australia, and France, which are countries that refer to prices in the decision-making process of domestic medical fees including Korea. First, in order to check the difference between the number of medical services in the study target countries, the detailed number of medical services for 32 surgical items was collected from 202 procedures. For the number of medical devices, the prices of 34 medium categories, and 2,835 medical devices were collected. For pharmaceuticals, price levels were collected by referring to 36 literatures. The collected fees were converted into US dollars using the general exchange rate and the purchasing power parity(PPP) exchange rate. In addition, the ANOVA F-test and Tukey post hoc test were performed using the SAS statistical analysis program to check whether there is a difference between the national averages in the collected medical fees. As a result, the P value of the fee for medical procedures and the fee for medical devices was 0.0001 or less, confirming that there was a significant difference between the averages of each country at the 1% significance level.

Next, medical demands, resources, services, health insurance system finances, degree of publicity of health insurance system, and regulatory strength were measured to examine the combination of causal conditions that determine medical fees. Measured values ​​were standardized in SAS, and then converted into fuzzy membership scores through the calibration function of Fs/QCA 3.0 software, and sufficient condition combination analysis using the truth table was performed. As a result, the combination that determines the high insurance benefit is the resource*~demand*~finance combination, and the combination that determines the low insurance benefit is the service*regulation*~publicity combination. The resource*~demand*~financial combination that determines the high cost of medical care is explained below.

First, if the medical resources available to the provider are abundant, but the medical demand and the financial level of the health insurance system are low, the provider will predict that the insurance fee covered by the health insurance system will be set low. Therefore, it can be explained that this prediction causes medical providers to offer high insurance fees in the process of determining the medical fees.

Second, in terms of the health insurance system, even if available medical resources are abundant, if the demand for healthcare is small and the financial support of the health insurance system is small, there will be concerns that a health care provider will not supply or reduce or withdraw existing supply. And these concerns are likely to lead to the acceptance of high insurance benefits.

The combination of service*regulation*~publicity that lowers the insurance benefit is explained as follows. First, on the provider's side, if the degree of publicity of health insurance system is low, so coverage is low, and low insurance benefits are expected due to strong regulations such as cost control, medical providers will respond to preserve profits by increasing the amount of services. In the health insurance system under this context, the insurance benefit is determined to be low. Second, if the amount of healthcare services increases despite the low publicity in the health insurance system, regulations such as cost containment will be strongly enforced to suppress the increase in medical expenses. Therefore, the insurance benefit is determined to be low as a result of this effect. As a result of the analysis of this study, the policy implications of the combination of causal conditions(resources*~demand*~finance) that determine the high insurance benefits are as follows. First, the health insurance system needs to increase financial support for some healthcare services (medical procedure, medical device, pharmaceuticals) that are expected to have low demand. Among the combinations of causal conditions that determine the high insurance benefit, the resource does not need to be modulated because it is abundant. However, it is difficult to control the low demand for healthcare in terms of the health insurance system. Since the health insurance system has limitations in regulating healthcare demand according to income and age. Therefore, in order to balance the high insurance benefits, it is necessary to expand financial support. However, expanding the finances for the entire healthcare service may increase the burden on the public because the source of financing is mostly premiums collected from health insurance subscribers. Thus, it is necessary to increase financial support preferentially for essential items directly related to life, although demand is small among healthcare services provided to consumers. Second, the health insurance system should provide adequate incentives to prevent health care providers from reducing or withdrawing supply due to low demand. For example, information of healthcare providers (hospitals, facilities, medical staffs such as doctors and nurses, private manufacturers and importers, etc.) is to disclose. Through this, it is to inform good providers of medical services despite the low demand in the healthcare market, and to provide incentives such as an additional fee to them to prevent reduction or withdrawal of supply. As a result of the analysis of this study, the policy implications of the combination of causal conditions(service*regulation*~publicity) that determine the low insurance benefits are as follows. First, the health insurance system needs gradual easing of regulations to adjust for low insurance benefits. However, at this time, policies to reduce the increase in the amount of healthcare services and increase the publicness of the health insurance system should be implemented together. As shown in the analysis results of this study, the regulation of the health insurance system is not the only factor in determining a low insurance benefit. As above, strong regulation, combined with a high amount of healthcare services and low publicity, determines low insurance benefits. Therefore, policies such as the following incentives such as deregulation on items that reduce the quantity and increase the quality of healthcare services should be considered. Second, the health insurance system should provide appropriate incentives for medical providers to improve the quality and decrease the quality of healthcare services. Among the causal conditions that determine the low insurance benefit, the low publicity of the health insurance system and the adjustment of high regulatory intensity are areas that the health insurance system or the government can do. However, controlling the amount of healthcare services is an area where healthcare providers and health insurance systems can work together. Therefore, the health insurance system should induce medical providers to improve the quality of healthcare services and reduce the quantity. An example of this is the Outcomes-Based Managed Entry Agreement (OBMEA) for each patient using real-world data recently implemented by the Health Insurance Review and Assessment Service. The drug to which the payment system is applied is KymriahⓇ(Tisagenlecleucel), a CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of patients up to 25 years of age with B-cell precursor acute lymphoblastic leukemia(ALL) that is refractory or in second or later relapse that has been the subject of controversy over its high price. When the evidence for clinical usefulness and safety is weak in determining the insurance benefit, the health insurance system is difficult to make a decision on reimbursement. This is because, rather than the financial burden of health insurance, serious life-threatening complications and uncertainty of results are more concerned. However, deregulation and providing payment based on actual clinical evidence and outcomes could reduce the amount of long-term healthcare for rare or severe diseases. Therefore, for the safety of patients as well as the efficient operation of the health insurance system, it is necessary to seek appropriate measures to improve the quality of healthcare together with healthcare providers. International comparative studies of factors determining insurance benefits have not been actively conducted due to the low transparency of medical fees internationally. Therefore, it needs to be reconstructed through more national examples and theoretical work in the future. In addition, this study could not deal with the lack of publicly available data on price transparency and distribution structure related to discounts, rebates, and negotiations for medical fees. As a future task, systematic research is needed by including it as one of the factors that determine the cost of healthcare.

의료수가란 의료서비스에 대해 보상하는 가격으로, 정부의 개입 하에 결정되기 때문에 정부와 의료공급자는 의료수가 수준의 적정성 문제를 두고 갈등을 빚는다. 이러한 갈등을 배경으로 본 연구는 첫째, 한국의 의료수가 수준이 다른 국가와 비교해 차이가 있는지 확인하고 둘째, 차이가 있다면 의료수가를 결정하는 원인조건의 조합은 어떤 것인지 고찰한다. 분석은 한국, 일본, 대만, 호주, 프랑스로 하였다. 먼저 연구대상 국가의 의료수가 간 차이를 확인하기 위하여 202개 의료행위 수가, 2,835개 품목의 치료재료 수가 정보를 수집하고, 의약품은 36편의 문헌을 참조하였다. 수집된 수가는 일반환율과 구매력 평가(PPP) 환율을 이용하여 환산하여 SAS를 이용해 분산분석을 시행하였다.

분석 결과 국가 간 의료수가(의료행위, 치료재료)의 평균 차이는 각각 1% 유의수준 내에서 유의미한 차이가 있었다(P<0.0001). 국가별 의료행위 수가의 수준은 PPP로 환산 시 일본(1.91) > 대만(0.99) > 한국(0.88) > 호주(0.70) > 프랑스(0.50) 순을 보였다. 치료재료 수가의 국가 별 수준은 PPP 환율로 환산 시 호주(1.15) > 일본(1.10) > 한국(1.07) > 대만(0.98) > 프랑스(0.72) 순이다. 한국의 의료수가(의료행위, 치료재료)는 중간 정도의 수가 수준으로 나타나며, 일본과 호주는 의료수가 수준이 높은 국가,대만과 프랑스는 의료수가 수준이 낮은 국가로 나타났다.

다음으로 의료수가를 결정하는 원인조건의 조합을 고찰하기 위해 의료수요, 자원, 서비스, 건강보험제도의 재정, 건강보험제도의 공공성 수준, 건강보험제도의 규제강도를 측정하였다. 측정값은 Fs/QCA 3.0을 통해 충분조건 조합분석을 시행하였다. 분석 결과 의료수가를 높게 결정하는 조합은 자원*~수요*~재정이다. 이는 첫째, 의료자원은 풍부하지만, 의료수요와 건강보험제도 재정 수준이 낮은 수준이면 공급자는 자신의 수익을 보전하기 위해 의료수가를 결정하는 과정에서 원가보다 높은 금액으로 의료수가를 제시할 가능성이 있다. 둘째, 건강보험제도의 측면에서 의료자원이 풍부하더라도 수요의 규모가 작고 지원할 수 있는 재정이 적을 경우, 의료공급자가 공급을 축소 또는 철회할 것이라는 우려로 인해 높은 의료수가를 수용할 가능성이 있다. 왜냐하면 제도는 공급 기피로 인한 진료의 차질 등의 문제를 실재로 경험하기 때문에 공급을 유지하기 위해 높은 의료수가를 결정하는 것이다. 의료수가를 낮게 결정하는 조합은 서비스*규제*~공공성이다. 건강보험제도의 공공성이 낮음에도 불구하고 의료서비스의 양이 증가하면 공공부문은 증가되는 의료비용 지출을 억제하기 위해 비용억제 등의 규제를 강하게 시행할 것이다. 따라서 이로 인한 효과로 의료수가는 낮게 결정되는 것으로 나타났다. 분석 결과 의료수가를 결정하는 원인조건의 조합이 갖는 정책적 함의는 첫째, 건강보험제도는 적은 수요가 예상되는 일부 의료서비스, 특히 생명과 직결된 필수적인 항목에 대한 재정지원을 늘릴 필요가 있다. 둘째, 제도는 적은 수요로 인한 민간 의료공급자의 공급 축소 또는 철회를 방지하기 위한 유인을 제공해야한다. 셋째, 제도는 민간의료공급자가 의료서비스의 질은 높이고 양은 감소시키도록 적절한 유인을 제공해야 한다. 본 연구는 국가사레가 적고 선행연구가 많이 이루어지지 않은 영역이기 때문에 이론적 기반과 모형의 적절성에 대한 근거가 다소 부족할 수 있다. 따라서 향후에 더 많은 국가 사례와 이론적 작업을 통해 재구성되어져야 할 필요성이 있다.